Amicus Maternity Center: Part IIby Jan Tritten

[Editor's note: This article first appeared in Midwifery Today Issue 85, Spring 2008. This is part two of a two-part series on Amicus Birth Center in Trinidad. Read online part one from Midwifery TodayIssue 84. We hope that this successful model can be used by others.]Photos provided by the author

The Practice

Amicus Maternity Clinic serves mostly middle-class women, but also rich and poor, educated and uneducated clients. One thing the clients have in common is that all of them want to avoid public hospitals. The Clinic does approximately 12–14 births per month, all onsite. A midwife is present at the birth center 24 hours a day so women can come in whenever they are in labor or have a question. Venus Mark says:

Venus Mark

Birth is conducted by whomever is on duty. The care is not fragmented because the midwife who starts the birth finishes it. Women can request their choice of midwife but usually they are happy to be served by the person on duty. Most of the midwives are willing to come in at the request of a client. If a midwife starts a birth she doesn’t leave until it is completed. Sometimes all rooms are occupied but the midwife on duty can call for help if she needs it. We have added to the birth center, especially to promote privacy.

No epidurals are done with midwife births. They are like homebirths; sometimes they end up on the floor, a chair or wherever. They are women-centered. The midwives follow the lead of the mother.

At Amicus we give women enough information that they don’t have to take a childbirth education course but they can if they want. I consider time with parents an investment. They do so much better when time is spent prenatally.

After birth women can go home in 8–12 hours. Most women stay for two days, depending somewhat on what they can afford. Longer stays incur more charges. Amicus also prepares meals for clients and family, if they choose. The client’s whole family is welcome to be present during labor and the birth.

Lisa Mark

Amicus follows the basic principles of the midwifery care model. In this philosophy, pregnancy and birth are considered to be normal; the mother’s overall well-being is monitored throughout; each mother receives education and other supports; technological interventions are minimized and those with true obstetrical needs are referred to the appropriate provider. Client preferences are deferred to, in general, although evidence-based standards also guide the practice.

Other than the Midwifery Model of Care, Amicus has no general philosophy of care. Venus notes that:

Each midwife needs to have her own [philosophy of care]. In my case, mom and family tell me of their plans but if an emergency arises I may need to intervene. We always try to honor the mom’s birth plans throughout. The baby goes right up on the mom. I feel midwives should not be constrained by my philosophy. They have their own thoughts. Our only real policy is from the government on prevention of AIDS.

Women must take back their bodies [and] midwives must take the steps themselves.

Venus believes that midwives must protect themselves and the moms they serve from high-tech medicine. They should not fear the doctors; many of those same doctors were delivered by midwives. She also believes that people are too much in awe of the initials after names, believing they make a person better equipped to sit with a woman while she delivers a baby. In reality, women are looking for a midwife, not a particular degree. Venus says “Birth; you can do it under a coconut tree if you know what you are doing!”

Besides midwifery care and support for its own patients, Amicus is a hub for breastfeeding mothers. Amicus is a part of The Informative Breastfeeding Service (TIBS) which means that even mothers who have birthed outside of Amicus can call for help and guidance with breastfeeding. TIBS was founded in 1977 to protect, promote and support breastfeeding. They advocate exclusive breastfeeding for the first six months of life, as well as continuing breastfeeding for up to two years, in conjunction with feeding solid foods.

Statistics and Techniques

Amicus has a very good record in terms of safety and non-intervention. From 1970 through 2003, the cesarean rate was only 8.9%. Breech births are not viewed as medical problems requiring cesarean sections if the babies don’t turn; they are born vaginally.

Amicus is also unique in that music and dancing are used during labor. Women are allowed to eat in labor, along with other choices they specify in a birth plan. Babies born preterm are cared for at Amicus, with their mothers, kangaroo-fashion. Since all babies stay with their mothers from birth, the rate of breastfeeding is 100%.

Barriers

Venus believes that one of the biggest barriers to the success of their clinic is competition and a lack of support from physicians.

Doctors seem to fear midwives in private practice. Medico-economics prevail. At first we got a couple of referrals. Then they would not refer. Possibly they fear us.

She believes in the necessity of “having an organization, a midwifery magazine and conferences to promote midwifery.” Without these additional resources, Venus believes that their job would be much harder.

In 2000, Amicus went through some difficult times when it was overstaffed and midwife managers did not understand the need to downsize in order to fit the client load. At that time the midwife-friendly obstetricians in the area had begun to establish their own private nursing homes, with maternity services, taking their patients there rather than to Amicus. The loss of revenue caused Amicus to rethink the model they needed to be successful and in the past two years Amicus has begun to build up again.

As a result, Amicus has begun to focus more on parent education. Debbie has found that word-of-mouth is one of Amicus’s best advertising methods. If Amicus can convince just one couple of the importance of birth and the positive role that Amicus can play in that birth, that couple will share that information with ten other couples. Selling families on the birth center helps the family and helps to ensure the survival of this unique and motherbaby-centric model. Venus adds: Women have information about their nice birth and happy babies are our best advertisements.

Amicus also advertises its services in supportive magazines and distributes brochures about their services at health fairs and other public venues.

Venus believes that another barrier to the continued survival of Amicus is that society still considers midwifery the next best thing. As a result, women often hire a midwife only because they cannot afford an obstetrician. Fortunately, more women are becoming enlightened about birth, so that is changing.

In addition, having an obstetrician-gynecologist on staff means that some women who don’t want a midwife will still be exposed to the clinic and the midwifery model of care. Perhaps the next time they will knowingly choose a midwife.

Another change that Amicus has made since its genesis is that they no longer accept referrals from obstetricians who are not supportive of their work. They found that associating with physicians who told pregnant women that “midwives are not safe” or “you should not have a midwife for your first baby” or otherwise indicated that they would not provide back-up was counterproductive to their work at the clinic. With an obstetrician on staff, this has become much less of a problem. According to Venus:

I was giving myself more stress than I needed. Women would need to change doctors so we would have a cohesive team. One night Debbie needed to consult with a doctor. The doctor abused Debbie and the woman. If you have any complication you need to be able to consult. It works better now that Lisa is here.

The clinic also has some financial challenges. Under the Trinidadian health care system, individuals have a choice of public or private care. All public care is free of charge; with private care either the individual pays out of pocket or an insurance company pays for care at a privately-owned institution. Amicus charges for midwifery care based on the amount of care needed or wanted. Many of the women stay for several days, but others do not. Insurance companies pay for the clinic’s services, but the government does not. Venus noted:

Ultimately people pay their bills, although it may take time. At least one woman pays for her last bill when she gets pregnant with her next baby….

The clinic really is not financially viable at this time. Since 1995 Venus has not been paid a salary by the clinic. She notes ironically:

It seems like I’m making money but I have 20 people to pay, garbage and many, many bills. Because we have our own business, people think we make money. This is not so. Births can’t really offset the bills but the building is paid for.

The practice can take care of the bills. I can’t afford to pay the midwives if I pay myself. Amicus sustains itself for staff, drugs, lights and so on but still goes into overdraft. We need to review the financial aspects of the whole thing. Midwives are paid a good salary, the same as the government standard for the country for midwives. We are currently reviewing the sustainability of this venture.

Despite the hardships, Venus encourages women who would like to start a birth center like Amicus to take the plunge.

Venus and Debbie are very good mentors. Debbie has been elected regional representative to International Confederation of Midwives (ICM) for the Americas. The two of them are willing to help other midwives get started in their dream.

Venus really is an independent midwife; for over 35 years she has been in business for herself. She believes that this model is one that could work in other Caribbean countries, due to similar laws. In addition, in the Caribbean, relationships between doctors and midwives are often good. Venus counsels developing those professional relationships while maintaining independence. She also recommends developing relationships with the nursing board, while maintaining an independent practice.

This is good advice for all midwives. In the US, nurse-midwives are losing their jobs because they lack independence. They are mostly connected to the medical profession, despite the fact that birth is not usually a medical event. To be sustainable we must be autonomous practitioners. Midwives specialize in keeping birth normal and knowing when to transfer care. Hooked to the medical profession we will never be truly independent. Too many obstacles exist, most of them based on assumptions. We cannot work in a system that looks at birth as power, money or an accident waiting to happen. We must be free as midwives to protect motherbaby from the medical culture and help them birth in accordance with our bodies’ design.

In order for another Caribbean country to successfully adapt this model, it would need to consider certain modifications to ensure that it remain financially viable. The income would need to be such that all staff could be paid for their work; most midwives are not able to work without pay. Even if they were able to provide free services, in the modern world work that is not paid is often considered by others to be of lesser value.

Amicus currently staffs the birth center 24 hours a day, seven days a week. By instituting an on-call system, the savings might be enough to pay an additional midwife. With 12–14 births per month, such a system may be entirely feasible.

Another possible solution to the financial problems would be to pay staff members a little less than the going rate or to pay more for actual midwifery work than for the reception, ordering of supplies, or time spent with little work. The joy of working in a congenial and supportive environment may make up for slightly less pay.

Most birth centers do not have full kitchen staff but have the kitchen available for use by families and staff who need to bring their own food and do their own clean-up. While providing this service undoubtedly raises the satisfaction level of the clientele, if it means the difference between success and failure, it is a service that is not essential.

Another solution might be to look into government funding so more people could take advantage of the care. Since health outcomes are no doubt better for Amicus clients than for the average population, perhaps some of the savings could be filtered back into the center so more health outcomes could improve.

When we think about models that work we can still look around the world and find these great examples we can emulate. So many of these excellent practices can be found throughout the world; we just need to look for them. It is time to start making steps to go with your dreams.

Repeat Cesarean?

Carmen and Stevens were having their second baby. They were admitted by their obstetrician for a repeat cesarean scheduled for 10:00 in the morning.

Throughout her admission, care and counseling by Venus, Carmen reported that she had been having diarrhea and cramps since the prior night. She said that on the drive that morning from San Fernando to Amicus, she was still experiencing “funny-like or menstrual pains.” At the same time her husband, Stevens, told Venus that he was praying real loud and hard that his baby would be born vaginally or delivered normally because he still didn’t know why Carmen had the first cesarean.

Venus answered, “My dears, the Higher Powers work in a Spiritual Mysterious way, His wonders to perform” because she could not tell them that they were in hot labour as she had seen. Nevertheless, she continued preparation according to the obstetrician’s request.
Within a half hour, Carmen said that she had to go to the bathroom for a bowel movement. Of course Venus knew what was happening, but did not want to alarm the family, so asked their permission to do a pelvic examination before she went to the toilet. Carmen was fully dialted and the vertex was resting nicely at the introitus. Since she was to have an obstetrician in attendance, she was taken to the delivery room with the anesthetist and obstetrician in tow. Just after she got there, the baby just slipped out or crawled out very nicely as Stevens was helping put her to bed for the doctor.

That was the best and most beautiful, spontaneous birth.

Frank Breech

Lisa’s first birth experience with Amicus involved a 31-year-old Gravida II, Para 1 woman. After her second visit with Dr. Lisa, she went into labour at midnight. Venus, who was on duty, called Lisa, informing her that her client was in labor with a frank breech presentation. When Lisa arrived she saw the buttock just appearing, although it still looked like a vertex.
They took their time getting the woman to the operating theatre because the family could not believe or come to terms with the fact that the baby would be born breech. The staff stayed with them, and they were able to comfort the mum; an ultrasound was even done in their presence. The pediatrician they had requested arrived as baby’s vertex exited. The young lady cried because of the intrusion and interferences. To this day this influential family is Dr. Lisa Mark’s Maternity Marketing Agent.

An Easy Breech Birth

Sonja, a very young primigravida, had an appointment with her obstetrician for probably the first time. The obstetrician called to say that she was sending the young lady from Port of Spain, a good twenty-mile ride—40 minutes to an hour away—from us at Amicus, so that we could evaluate her to determine whether she was having labour pains or just menstrual cramps.
The young lady arrived at Amicus, and as always a midwife was at the front desk. Sonja was taken immediately to the birth room and she was found to have a baby in a frank breech presentation. This young client continued doing what she was doing on her own unconsciously, until her baby girl, a sprightly 5 lbs, was born crying lustily. Young Sonja explained to us after the episode and birth that she had had a terrible cramp in her tummy in class, and they had rushed her to the doctor who sent her to us. She didn’t know that she was pregnant and at full term.
The family came and was very happy that their daughter was well cared for and there was no insecurity or exposure or scandal to the public. Sonja returned to classes the next week.

Jan Tritten

Jan Tritten is the founder and editor-in-chief of Midwifery Today magazine and a midwife who was in active practice from 1977–1989. She became a midwife in 1977 after the powerful homebirth of one of her daughters. Her mission is to make loving midwifery care the norm for birthing women and their babies throughout the world. Meet Jan at our conferences
around the world! [ PHOTO BY ANDREA NOLL ]

1947 Born in Los Angeles, California.1965 Graduated from Placer High School in Auburn, California.1966 Trained for one year as a psychiatric technician. Courses included
basic nursing, pharmacology, microbiology, anatomy and physiology, psychology.1966–1971 Worked at DeWitt State Hospital in Auburn, California
as a psychiatric technician.1968 Graduated from Sierra College with an Associate of Arts degree.1970 Graduated with honors from Sacramento State College with a
Bachelor of Arts degree in Social Science.1971 Earned Lifetime California teaching credential with fifth-year
program from Sacramento State College.1972 First daughter born in a hospital. It changed my
life forever. It was an unsatisfactory birth experience, but I had a wonderful
postpartum experience with 2-1/2 years of breastfeeding.1976 Second daughter born. She was born at home
with a doctor who talked me into a homebirth. The difference between the
two births sent me on a path to do something to help women have positive
birth experiences.1976 Began training as a midwife. Because I was raising young children
and running a business, and because there were no CNM schools in my area,
becoming a CNM was not within my reach.1977 Began attending births with the Birth Co-op in Eugene while
organizing courses in our community taught by CNMs, physicians, nutritionists,
etc.1978 Began a midwifery practice, New Life Care, with a partner,
Chris Howard, and apprentice Monika Dunsmore.1979 Son born at home.1980 Did a one-year program with Marion Toepke McLean, CNM. Four of us completed the program, which was modeled after CNM curriculum at that time. She took a year off from her practice to teach us and to go to our births with us.1982 First group of midwives certified by the Oregon Midwives Council.
Our board was composed of CNMs and physicians.1986 Slowed down practice and started Midwifery Today magazine.

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